| NPI | 1912741844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA066862) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0009631) |
| Enumeration Date | 2024-06-24 |
| Last Update Date | 2025-10-29 |